HomeMy WebLinkAbout07-27-11 (2) 105.905 RF.V.(I/11)
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This is to certify that this is a true copy of the record which is on file in the Pennsylvania De artme ~ ~ . ~ ~ ^ ~ U
the Vital Statistics Law of 1953, as amended. P nt of Health, in accordance with
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Marina O'Reilly Matthew
Acting State Registrar
6.289860 _
JUl 19 » ~-7
No. -- .- --.. ~ ;
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H105.143 REV 11rZ006 - - ~ , _-.~
Tel: /N COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS t_ _ r ~~
~`"~"'"~ CERTIFICATE OF DEATH ~ ~ -n ~=
(See instructions and examples on reverse) ~ R'~ '~"~ t">"d
1 • Nerve d Decedent (Fsst, middle, lest, sutra) , £~TATE FILE NUMBER "Q -1 ~~
I C~ _ , r! I i lnn~ ~ V" 2. Sex 3. Boreal Securky Number 4. Daro d (Month, day, year) ~r
5. Age (last Birtlrday) Under 1 r (}.V (~ 4• Y 1 , f m ~ g - ~ O --
Under 1 6. Dade d Bill Madh, 7. Bi and slate a rare'
Merits pays tdaus µ~ Q Ba. Place of Death (~recdc one
` ~ ~ / ~ ! / ~ ~ D I Q ^ • Hospital: Other.
Yrs. (~ ` 4./ru'
6b. County d Death 8c. City, Bero, Twp. of Death Inpatient ^ ER / Ou~atient ^ DOA ^
~ ` fid. Faddy Name (ff rat institution, give street and number) 9. Was Decedent d Ifspanic Origin? Nursug How ^ Residences ^ Other • Specify:
~bQV I Q~,r~ (tl yes, spadfy Cuban, Ne ^ Yes 10. Race: American Inrlian, Black, Whim, etc.
• CSI, s 1 ~ 1 ~ 5 ~ K as ~~~ (
Mexicen, Puerto Rican, etc.) n
• 11. Decedent's Usud lion d work done du ' most d Ifie. Do not state reti 12 Was Decedent ever n the 13. s Educatbn
~ d Wont IGrd d Business/Industry U.S. Amsd Faces? (~~ onty ~ car~leted) 14. Marital Status: Married, Never Married, 15. Surviving Spouse (tl wde, give maiden name)
Elementary I Secondary (0.12) Cogege (1.4 or 5+) wxlowed, Divorced (specify)
rtr F' ~ Yes ^ No ~
` 16. `DlIecedenPns iMaiing (Stree4 sty/tam, state, zip code) D¢cedenrs /~
I `Q U D~.~Q~Y Rd , ~ ~ Actual Residence 17a. State ~!'t• ~ y~/~
T ~s1°hipv 17c. ~ Yes, Decedent Lived'm - r I DYl ir'r, ~ T~
• ~ "~ 17b. County ~ 17d. ^ No, Decadent Lived within
16. Fathers Name (First, midde, last, so(fa)
Actual Limits of City/Boro
1, 19. MoOrers Name (Fnst, middle, maiden surname)
V l.~ ' lrn
20a. kdomnant's Name (Type I Print) '
20b. kdomtenrs Madirng Address (Street, dry /row,,, state, rip code)
~ ~ 21a Metlad d Dh , ~ S w^ ,
^ Cremation ^ Danation 21b. Date d D' I
^~ sposition (Month, day, year) 21c. Place d Disposition (Name d cemetery, crematory a otlar e) 21d. Locefbn (City ,state, tip code)
w° yal Buret ^ Removal Iran Slate i Wes Cron or Donatlon Authorhed c ^ IA
`~ ^ der - r by Medial Eatminer/Coroner? ^ Yes^ No J o1 Jul o~ b ~' ~r l ~•2~~~ ~
• 71a. of Funeral Service Licensee la as such
~ hirn.~av,s~wi~,P~ 17011
22b. License Nar~ber 22c. Name end Address d Fadtily
Compleb tiers 23a~ ordy when 9 23a. To the best d ` ,death occurred at the time, faro end place stated. (Signature and title) ~ ' ` C i ~ ~ i)
plrysidan is nd available at tare d death ro 23b. Dense Number 23c. Da S' ,
certlTy terse d death. ~ m ~ ~ 3?~l 9,1 ~ d~ ~ y r '~ t
~ Items 24.26 must be oanpleted by person 24. Tors d Death 25. Date P Dead (Mo tu, day, year) ~
• '"h0 a01r°er~s death I ~ , ~ f~ M, e~ ~r ' ^ 26. Was Case Refe ro Medical ExarMner I Coroner far a Reason Other than Cremation a Daration?
( V / W ~ ~ • ^ Yes No
CAUSE OF DEATH (See inatructdona and a mples)
Ihm Z7. Part I: Eller 1he~N 0f - dseasas, .. a r Approximate artervat: Part tl: Enter otlrer ' ~ 26. Did Tobacco Use Contribute ro Deaths
xqurnes, nbmpications - tlnat fierily caused tls death. DO NOT enter terminal everts such as ardac arrest, r Onset ro Death
respirerory arrest, a venti'kxder tibrilatiorr wilhart s{t~jra the etlology. List ady as cause on each line. i but rat resulting rcr the underlying cause giver in Part I. ^ Yes ^ Probably
cerrddon $mE~m) dseese a </) _ r No ^ Unlmoxm
~. } ~ _ n
,' Duero (or as a casequercee i 29. I Female:
'i ~ uist oondibars d any b ~ r ^ Not pregnant witlrin past year
b ause fsbd on tare a. n ^ Pregnant at tinne d death
Errer UNDERLYING CAUSE Duero (a as a carsegnterxa o : r
. events resrdting~ m death) LAST c. ~ ~ ^ Nd pregnant, but pregnant within 42 days
` n of death
Duero (a as a corsetpsrae ofj: r
d r ^ Not pregnant, but pregnant 43 days ro 1 year
n before death
Unknownnrf
30a. Was an Auopsy 30b. Were Autopsy Fandsrgs 31. Manna d Death n Pre9reM wdhin the past year
Performed? AvadaMe Prior to Completion 32a. Date d Injury (Month, day, year) 32b. Descrhe How Injury Occurred
d Cress d Death? ~Na~ ^ Homipde 32c. Place d Injory: Hans, Farm, Street, Factory,
// Office Buffing, etc. (SPsa(y)
^ Yes ~No ^ Yes ~ No ^ Aoddent ^ Pending Imrestigation 32d. Time of Injury 32e. Injury at Wak? 32f. If Transportation I 'u
ry ry (SP~y) 32g. Location d injury (Street, dty /town, stale)
^ Suidde ^ toff Nod be Dehmnasd M ^ Yes ^ No 0 ~ r/Operator ^ Passenger ^ Pedesldan
` 33a Certifier (deck anty are) h•'
~iMn9 Phyaicien (Physidan cerUfyarg pose d death when anotlar 33b. signature and Ti of rtifsr
To the beat of my knowkdgc, loth occurred due to the a ~~ has proranaceed death and comphted Item 23) ~
use(s)arndmenneresstated--------------------------------- ^
• P-onouncing end certHytrrg ptrysichrn (Phydden both praarncang deatln and certl(ying ro case d death) 33c. Liceree Number
~ To the best d my lmowkdge, deetlr ocenrmed M the Ome, date, and place, and due to the cause(s) and manner as stated_ _ N/r, ~' ~ '~ /Ma/~h
W • Medial EmnmalCaoner - - - - - -~ I, r 3 ~ ~,~ 0 ' I ' ~ o !I s
W
~ On tine bash d examination and f or imresligeUon, in my opinion, death occurred at the time, date and plea, and due to the ause(s) and manner es eteted_ ^ 34.
o d o Per~Who_ Canplehd [;auseod peeth it ~m ~ Type f Pmd ,rte ~~ l~r f
~ 35. Registrars Sgreture and Number 36. DadeFded( ,reor) y' 'Q• r+n'j,u /lvA.pA_/ 3 Y ~~C I~ s•"1
z ~ ?~ d~F~C~ L ~ ~ I C~ 1 01 01
D 7 / ,20 CA~Q 1.1 S LC A I a0 ! S- • R°,
Disposition Permit No.
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